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The Choices We Make Dictate The Life We Lead

What can we expect — and what do we think we need — to handle the kidney disease population over the next 30 years?

Having helped nephrologists, young and old, find employment over the last 30+ years, it’s my view that the specialty is at a crossroads.

The American Society of Nephrology recently completed a study on physician workforce to identify many of the concerns impacting the specialty. The report, entitled “The US Nephrology Workforce 2015: Developments and Trends,”1 raised five major interrelated workforce issues that the Society believes need to be closely watched.

• The inter-professional education and practice for nephrologists The task force took great pains to not only evaluate the numbers, but evaluate trends and speak with focus groups of practicing nephrologists. They also conducted interviews with some of the major dialysis providers.

Addressing manpower early

Nephrologist supply was originally addressed back in 1997. The Ad Hoc Committee on Nephrology Manpower Needs developed the report, “Is the specialty prepared to meet the needs and if not what needs to be done to address those needs? That report was completed by the ASN along with the National Kidney Foundation, the Renal Physicians Association, the American Society of Transplant Physicians, and the American Society of Pediatric Nephrology. Although the numbers of nephrologist in the specialty have more than doubled since that time, so has the number of patients with end-stage and chronic kidney disease. The concerns for this specialty’s manpower future has never been greater.

In 1997, meeting the demand

The manpower problems are somewhat different today. Back in 1997, the concern was whether there would be enough nephrologists to meet the needs of the patient population in 2010. The report considered specialty population, aging factors, fellowship programs, and the numbers of physicians they could produce and the overall growth of kidney disease, which at that time was running close to 9% a year.

Today, manpower remains the issue but the problems are different.

• Growth of the ESRD population has stabilized and is at a significantly lower rate than in 1997.

• There are significantly more fellowship slots available today than there were in 1997, but many of them are not being filled.

• Many of the fellows coming out of nephrology training are not practicing nephrology when they get out. There is a real debate as to whether there is an oversupply or undersupply of nephrologists to meet current and future needs.

In 2015, what are the needs?

The ASN-led report, “The US Nephrology Workforce 2015: Developments and Trends,” suggests a reduction in medical graduates may be warranted. One of those fac-tors includes comments from fel-lows complaining that the job mar-ket remains limited, and dialysis providers claim that cost pressures and financial incentives may lead to steps toward improving efficiency—including a reduction in demand for nephrologists.

Is that really the case, or are fellows coming out of medical training fully prepared for a future in nephrology? I asked chief medical officers at the leading dialysis companies about preparation and demand for more nephrologists. Said Frank Maddux, MD, Chief Medical Officer of Fresenius Medical Care North America: “The industry could consume most if not all of the nephrologists produced if there was flexibility in location of residence and additional training in leadership skills, interdis-ciplinary team leadership, population management, outpatient advanced renal disease care, and skills to support a higher attention to cardiovascular needs of the renal patient population.”

Perhaps reducing the numbers of slots would increase fill rates. But maybe fellowship programs need to consider a curriculum adjustment—one that better prepares nephrology fellows about “real world” practice in addition to traditional training models. The industry may have to look at ways to adapt to new pay struc-tures that make nephrology more attractive to younger physicians and conform to the attributes of their professional career aspirations. The Match numbers for nephrology have been dismal at best. According to the report, “Nephrology had the lowest fill rate of any IM subspecialty in the 2015 SMS (Specialty Matching Service) Match and the lowest match rate for those with US MDs. Only 276 individuals applied for 374 nephrol-ogy position in 2015...”

Where is the money?

“Why” is the big question. For those fellows looking at going into private practice- compensation, work expectations, work load, call, and practice stability are major factors.

Let’s start with a look at compen-sation. In looking at the most recent 2016 Medical Group Management Association Starting Salary Survey3done in collaboration with the National Association of Physician Recruiters (utilizing 2015 data), the numbers tell the story (median numbers–first-year post-fellowship).

Even allergy and immunology, endocrinology and infectious dis-ease make more in their first year than nephrology does with the median of $170,000. Many nephrologists look at going into Hospitalist posi-tions, which start in the low to mid $200,000 range ($215,000 @ MGMA figures) and affords a better lifestyle. But starting salaries do not tell the whole story and this is where the American Society of Nephrology and the whole Nephrology community needs to do a better job of laying things out for Fellows and Residents.

Dylan Steer, MD, Chief Executive Officer and President of Balboa Nephrology Medical Group, a 40 phy-sician nephrology practice based out of San Diego, stated, “Starting sala-ries in nephrology are generally not great indicators of potential. In private practice nephrology, for example, the MGMA average for a small group nephrology practice is slightly over $300,000. This would indicate that there is significant growth potential and salary escalation over time. There are also many other lucrative rev-enue streams available to nephrologists that may not be captured in that income figure. Hospitalists gener-ally have a flat income over time with limited options to develop ancillary revenue streams.”

The MSMA compensation numbers bore that out. If one com-pares 2015 MGMA4 compensation numbers for a hospitalist and a nephrologist over a 30-year career, the nephrologist makes almost $1.9 million more (22%), not including additional revenue streams such as Medical Directorship and Joint Ventures.

Why are starting salaries so low? Part of it may be the specialty itself and how revenues are generated. According to the Renal Physicians Association 2015 Benchmark Survey,5 approximately 31.5% of a full-time physician’s revenues come directly from seeing patients in the dialysis units (the percentage is less for those practices doing vascular access). Someone coming out of fellowship does not generate significant dollars from dialysis starting out and will take several years to get their patient volume up to that percentage.

Besides compensation, Dr. Steer points out: “Some fellows I see are very interested in ‘work-life’ balance and believe that nephrology can’t accommodate that interest. I’d tell them that although nephrologists generally work fairly hard and take care of sick people, work-life balance is absolutely attainable in this specialty. I believe work-life balance is more a function of the physician than the specialty.

”Finding a “satisfactory” position

Another area raised in the report was that fellows coming out of train-ing are unable to find satisfactory positions. The report does not elaborate on what is a satisfactory position or whether initial expectations for a position are realistic. Experience indicates that a satisfactory position (to be used as a basis for interviewing) would be in a location desired, with a call schedule desired (not necessarily realistic), minimal driving time, compensation (not necessarily realistic), practice stability and partnership.

Dr. Steer said, “Often, I see fellows with unrealistic expectations of what a starting job looks like. It takes a concerted effort, time, and patience to succeed. Many of the skills that will determine success, such as an ability to work well with others, or team-work, are difficult to teach.”

According to Ruben Velez, MD, former Chief Executive Officer and President of Dallas Nephrology Associates, “The new training regulations have significantly changed and limited the training of future physicians in general, not just nephrology. The new regulations control the hours and the number of patients you are exposed to.

“The experience that Fellows used to get was far greater than what they get today. I have seen renal fellows less exposed to different situations. They did this with the intent of trying to protect the residents (not to burn them out). At the same time, it has given the wrong impression of reality in the private world. For example, fellows are not limited in admissions, consults or hours they may need to work. Rare for you to go home early because you were on call the night before.

“Robert Provenzano, MD, Vice President of Medical Affairs for Davita Kidney Care, mirrored those comments when he stated, “Fellows coming out are often ill-prepared for the workload of private practice. Their fellowships are ‘protected’ by RRC work rules so they actually work harder in practice then they did in fellowship. This is 360 degrees different than in the past when there were no work restrictions during fellowship training.

“This generation appropriately focuses on work-life balance, much differently than earlier generations so this has to be considered during the interview process.”

Another factor to consider that has a direct impact on Internal Medicine Resident interest in specialty is what they hear from former Fellows and Attending’s about their own experiences in the job market. From an American Medical Graduate perspective, outstanding loans are generally high and focusing on a specialty with a low starting salary. As Dr. Provenzano puts it, “Graduates are in debt, so they opt to do Hospitalist work to pay down that debt. There is a bill in Congress (S.840-Student Loan Borrower Bill of Rights) now that will allow employers to pay off the student loan. That would be a major advantage to relieve this issue.”

With the specialty now being over 50% international medical graduates (IMGs) and fellows falling within a consistent range over the last few years of 65% (73% being IMGs) their expectations are different. For the majority of IMGs, they do not have the loan concerns that American medical graduates have, but many have already put in additional years of training in their home country or elsewhere and then they are required to repeat the training here.

After completing the training, a good percentage of those then have to deal with visa obligations ( J1 or H1B visas), which may force them to take positions that fulfill their visa requirements to stay in the United States but are not necessarily their position of choice. From the IMG’s perspective they have now done five (or six) years of repeat training plus (if on a visa) another three years to fulfill those requirements and only then do they go to a practice where they can look to having a future. It is basically starting over at that point: they look at having to work another two or three years before they are in the position of being offered a partnership as something that is a big risk. It’s just not worth it.

They have heard horror stories from their more experienced peers not being offered partnership, or not getting the Medical Directorships promised or not being allowed to participate in joint venture opportunities. As one nephrologist three years out of training put it, “There is greed in nephrology; many of the older physicians do not want to share and ultimately, they do not. There is a lack of stability for fellows going into practices and no guarantees that after all your efforts that you will get a fair shake.”

He believes this concern is another factor as to why residents are not going into the specialty or nephrologists coming out of training choose an employed Hospitalist position. These thought or similar have been shared by numerous nephrology fellows interviewed (all of which request anonymity for obvious reasons). There are nephrology practices out there that have a reputation for hiring, working people unfairly and then firing them without offering anything. In other cases, there are limited opportunities to joint venture and many practices in popular locations have the bulk of their units already opened with limited growth available. These are issues the residents and fellows are wrestling with that make the decision to go into nephrology a difficult one.

Next steps

What needs to be done? Velez responded, “The problems are real. We work too hard; we don’t make as much as some of the other sub-specialties and our patients can be complicated. But that said, would I do it again? Yes, absolutely...We have to put the love and respect back into nephrology,” said Velez. “I remember working till midnight with my attending’s, and I loved it. We lost that. We were working hard but it was enjoyable.”

What made a difference for Velez? “In the past we had great mentors. I know I was blessed to have them. I worked with some of the brightest, intelligent people on earth and I still feel that way. They are still out there, but we lost that kind of mentorship somewhere along the line. And when I trained, we would rotate with the private nephrologist in the community. It was a wonderful experience for me—to come out of an academic setting and see how the rest of the world was practicing.

Maybe we need to promote some of the things that attract physicians to the specialty. Velez’s idea: “Every other sub-specialty limits itself to taking care of a specific organ, while nephrology takes care of the whole body. Everything is connected and involved. It is really a subspecialty that you have to have the knowledge and experience more than just dialysis ." ”Fellowship training today struggles from a number of challenges,” says FMCNA’s Maddux.

“Fellowship programs today are predominantly acute care-based and much of this important training is very different clinically from what a nephrologist will spend much professional time when practicing in a community based environment. Fellowship training programs might consider balancing the important inpatient training with skills that support an outpatient value based clinical practice model.

”Moving forward"

There are things that need to be done to put the nephrology specialty on track and get people interested in nephrology again. But it is going to take a lot of hard work and an effort among all factions working together to make it happen.

Of note: According to Medscape Lifestyle Report 2016: Bias and Burnout, nephrologists rated fourth highest out of 25 specialties when physicians were asked whether they were either very or extremely happy at work. Nephrologists ranked number one when asked the same question about their happiness at home.

The future for nephrology does not have to be grim changes in the way fellows are trained, nephrologists practice and compensation is generated and distributed have to be made, and they can be. But it has to happen soon.